Sample Reference Release Form by evk20444


									Sample Reference Release Form
The following document is a recommended              form for nonprofit
employers to obtain information from prior           employers about the
applicant’s qualifications for the open               job position. The
questions can be modified to reflect other           applicable criteria
for the open job position.

                       Reference Release Form
Applicant name: _________________________________________
Former employer:__________________________________________
Applicant’s Social Security #:____________________________
Dates employed:   ________________________________________

                        Applicant’s Authorization
I consent to and authorize the above-named former employer, and its agents
and employees, to furnish any reference information concerning me, including
achievement,  wage   history,  performance,   attendance,  personal  history,
disciplinary information and reason for separation of employment, relating to
my employment with the former employer. I also hereby release and indemnify
the above-named former employer, and its agents and employees, from and
against all liability for damages or claims including, but not limited to
defamation, interference with contract, or prospective economic advantage and
negligence, I have or may have which arise or result from any reference
information provided pursuant to this authorization.

Applicant’s signature: ________________________________________
Date:                  ________________________________________
For completion by former employer:
                        Record of Employment
Position held: _______________________________________________
Dates employed: _______________________________________________
Summary of essential duties:___________________________________

Reason for leaving: ____________________________________________
Salary at termination:
    Eligible for rehire?          Yes         No

Please rate the following: Excellent Good           Average      Poor
    Job Knowledge          _____     _____          _____         ____

    Attendance               _____       _____       _____       ____

    Productivity             _____       _____       _____       ____

    Degree of Supervision    _____       _____       _____       ____
Dependability   _____   _____   _____   ____
    Overall Attitude      _____       _____      _____         ____
    Overall Performance    _____      _____      _____         ____


Signature:        ___

Title:                                     Date: _______

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